Red Flags. Sx > 6 weeks. Trauma. Unexplained wt loss. age > 50 with comp fx or hx of osteoporosis. Age > 70. Fever, infection
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1 Acute Low Back Pain Most common cause of disability < 45 y Cost: Billions (US) annually in dx, rx, lost work time Acute uncomplicated (no red flags) is self limited - No imaging required. Need for focused Hx, PE If necessary pain meds and PT Imaging required if Pain >6 weeks or red flags
2 Remember ABCS! Accuracy: MRI > CT Lumbar > X-Ray > Bone Scan; except for bone where MRI = CT. Know your risk (prevalence = variants) Benefits/Cost: Likelihood of finding optimal Rx by getting test vs risks (Rx, Disease, Test) Source: Make sure quality site (ACR certified, reputation)
3 Red Flags Sx > 6 weeks Trauma Unexplained wt loss age > 50 with comp fx or hx of osteoporosis Age > 70 Fever, infection Immune system down or diabetes
4 Red Flags Hx of Cancer Intravenous Drug Use Focal or Progressive Neuro Sx Prolonged Steroid Use or Osteoporosis Surgery
5 ACR ratings (1-9) Variant 1 (Imaging Tests for Uncomplicated Acute Low Back Pain) MRI Lumbar Spine (No contrast) 2 X-Ray Lumbar Spine 2 CT Lumbar Spine (No contrast) 2 X-Ray Myelography of Lumbar Spine 2 Bone Scan with SPECT 2 CT Lumbar Spine without contrast 2 CT Lumbar Spine with contrast 2 MRI Lumbar Spine with and without contrast 2 CT Lumbar Spine with and without contrast 1
6 ACR Ratings: Variant 2 (low velocity trauma, focal or progressive deficit, osteoporosis, prolonged sx > 70) MRI Lumbar Spine without contrast 8 CT Lumbar Spine without contrast 6 X-Ray Lumbar Spine 6
7 ACR Ratings: Variant 3 (Cancer, Infection, Decreased Immune System) MRI Lumbar Spine with and without contrast 8 MRI without contrast 7 CT Lumbar Spine with contrast 6 CT Lumbar Spine without contrast 6 X-Ray Lumbar Spine 5 Bone Scan 5
8 Relative Radiation Exposure MRI lumbar Spine 0 CT Lumbar Spine with contrast *** CT Lumbar Spine without contrast *** CT Lumbar Spine with and without contrast **** Bone Scan *** Note *** = msv; **** = 3-10 msv
9 The Future Improved Accuracy Genetic Testing Metabolic Testing Successful Treatments Biomarkers Funding/Payment/Justice/Ethics
10 ABCS Still Apply Accuracy (100% goal) Benefits (Prevention allowed, Rx successful) Costs ($, Harms Test/Disease/Rx) Source (Best Places - Best Results)
11 Genetic Tests Only Beginning - Entire Genome Sequenced Examples (BRCA1, BRCA2, enzyme deficiency disorders) Improve risk assessment (prevalence) Used in sequence with other test(s) or alone if sufficient for Rx/No Rx
12 Alzheimer Disease Affects 5,000,000 Americans Majority of Cases in elderly but 1-5% under age of % lifetime risk in general population Increases 2 to 3 fold in patients with APOE E4 heterozygous allele (one copy) and 2-10 fold in homozygotes (Both copies of gene)
13 Sx, no family hx Need accurate assessment of sx, formal neuropsychiatric test by reputable specialist 1st step. May obviate need for any other testing (genetic or any other) If equivocal psych test, genetic test still likely to provide confusing results. Consider effects of positive, negative test and the cost (may need to pay out of pocket) Testing may be indicated in special circumstances. Discuss with provider
14 Strong family hx Genetic tests in this risk group may have value in ruling in (specificity (spin) and ruling out (sensitivity (snout)
15 Metabolic Tests Already expressed metabolites or other markers Indicate disease status/response/prognosis Guide Rx decisions Cancer: CEA HIV: Immune System Markers, Viral Load Liver Injury (Infection/Toxic): LFTS, Ab, Ag
16 What s UP Next? New Markers and Inventions Genetic and Metabolic Ongoing health monitoring (weight, blood pressure, pulse, blood oxygen level, blood sugar level, other markers of disease)
17 Smart Toilet? Monitors human waste products (urine, feces) for blood, shed cells, metabolites for early detection of disease Rich baseline data developed. Changes can flag patient as needing provider evaluation. Yearly check-up becomes thing of past
18 Questions?
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